Application Form Applicant InformationApplicants are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, I or any other prohibited basis of discrimination, as provided under applicable state and federal law.Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone #*(including area code)General Work HistoryHave You Ever Been Employed By Friendship Haven, Inc.?*YesNoIf yes, under what name?Date Last WorkedPosition HeldReason For DeparturePosition For Which You Are Applying?*Expected WageWhen Can You Start?Hours You Would Like To Work Per Week?*5-15 Hours/Week15-30 Hours/Week30-40 Hours/Week40 Hours/WeekShift Preference* Morning Afternoon Night Are You Willing To Work Weekends?*YesNoAre You Willing To Work Holidays?*YesNoWhat/Who Prompted You To Apply Here?List Any Relatives That Work HereIf Under 16, Can You Obtain a Permit To Work?YesNoNot ApplicableAre you physically and mentally able to perform the essential functions of the job for which you are applying with or without reasonable accomodation?*YesNoIf No, Please ExplainDo you have a record of founded child or dependent adult abuse in this state or any other state?*YesNoIf Yes, Please ExplainHave you ever been convicted of a crime, in this state or any other state?*YesNoIf Yes, Please ExplainA conviction record will not necessarily be a bar to employment. Factors, such as age and timing of offense, seriousness and nature of the violation and rehabilitation will be taken into account.Do you have a nursing license?*YesNoType of LicenseRNLPNRegistration #StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you a certified nursing assistant?*YesNoIf hired, can you furnish proof that you are eligible to work in the United States?*YesNoIf unsure of the documents needed to prove eligibility to work in the U.S., we will be happy to explain the legal requirements.If No, Please ExplainEducational HistoryHighest Level of Education Completed*Grade SchoolHigh SchoolCollegeGraduate SchoolBusiness/TechnicalHigh School*High School/LocationCourse/MajorGraduated (Yes/No) CollegeCollege/LocationCourse/MajorDegree (Yes/No) Business, Technical, Night or Correspondence/LocationSchool/LocationCourse/MajorDegree (Yes/No) Employment HistoryPlease begin with the most recent.May we contact your present employer?*YesNoEmployer*CompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date EmployerCompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date EmployerCompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date ReferencesPlease list names, addresses and telephone numbers of the three persons other than relatives and employers with whom you are acquainted.Reference #1*NameHow do you know them?AddressPhone # Reference #2*NameHow do you know them?AddressPhone # Reference #3*NameHow do you know them?AddressPhone # Additional InformationComments/QuestionsUse this space to provide any additional information that might be useful in considering you for employment.Attach an Optional RésuméAccepted file types: pdf, docx.(PDF or Word Doc)Attach an Optional Cover LetterAccepted file types: pdf, docx.(PDF or Word Doc)